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Venipuncture Site Selection

• Venipuncture sites should be avoided if the location has extensive scars due to burns or surgery, to avoid puncturing the scar tissue.
• Avoid the upper extremity on the side of a previous mastectomy because test results may be affected by lymphedema.
• Do not use sites with Hematoma, which may cause erroneous test results; if there is no other viable site, collect the specimen distal to the hematoma.
• Do not use Edematous extremities, tissue fluid accumulation alters test results.

Drawing Issues

• Drawing blood from intravenous lines avoids difficult venipuncture, but the line must be flushed first.
• When using a syringe via an intravenous line blood must be withdrawn slowly to avoid hemolysis.
• Blood should not be drawn from an arm with a fistula or cannula without consulting the attending physician.

Needle Insertion Angle

• Insertion at an angle of incidence of 15 – 30 degrees is recommended.
• When the bevel of the needle is fully inserted in the lumen of the vein within a 15-30 degree angle, the needle placement is optimal
• Too steep a needle angle increases the potential for the needle to completely penetrate the vein, causing a hematoma.
• When the needle angle is too shallow, the bevel will rest on the wall of the vein and may result in formation of a hematoma.

Missed Vein

• When approaching the missed vein, continue in the same direction
• Ensure the direction of the vein.
• When performing on a running vein, the skin needs to be anchored.

Phlebotomy in Geriatric Patients

• In elderly patients, use a butterfly needle.
• The skin commonly becomes thinner and looser, and the muscles also become smaller, causing veins to roll easier, become less elastic, and be easily injured or collapsed during a venipuncture.

Geriatric Phlebotomy Tips

• Elderly patients are prone to bruising; place the tourniquet over the patient's shirt sleeve if drawing an arm vein.
• The tourniquet should not be applied too tightly because it could cause injury or collapse the vein, and should remain tied for no more than one minute at a time.
• Elderly patients' veins have a tendency to move easily.
• Gently pull the skin taut and anchor the vein using thumb.
• Puncture the elderly patient's vein in a quick, smooth motion.
• The needle should be inserted at a decreased angle since the veins are close to the surface of the skin.
• Choose a straight section of the hand vein, avoiding any "intersection” or “V” where a vein branches into another vein.
• Apply pressure on the site for three to five minutes or until the bleeding has stopped to prevent bruises or hematoma.
• Older patients are more sensitive to standard adhesive bandages.

Phlebotomy in Paediatric Patients

• Pediatric blood collection may be by skin puncture or venipuncture.
• Skill in pediatric phlebotomy is gained through knowledge of special collection equipment, observation of skilled phlebotomists and practice.
• Paediatric patients can be very challenging due to size and emotional response to blood collection.
• Competence in phlebotomy for older children should be acquired before younger children.
• A phlebotomist should recognize limitations, always request help when necessary.
• Pain alleviation considerations through topical anesthetic EMLA can numb surface skin for a short time.
• The dorsal hand technique is appropriate for neonates and infants who are younger than 2 years old.
• Use a 23g Butterfly Blood Collection Set attached to a 3-5 ml syringe when performing a dorsal hand venipuncture.

Complications of Phlebotomy

• Move forward or backward
• Adjust the angle of the needle if an incomplete collection occurs, and loosen the tourniquet.
• Apply pressure to the puncture site for 5 min.
• A hematoma forms under the skin adjacent to the puncture site, release the tourniquet immediately, and withdraw the needle.
• Apply firm pressure.

Hematoma

• Hematoma formation is the most common complication of venipuncture and is caused by blood leaking into the tissues during or after venipuncture after failure to penetrate the vein properly during insertion.

• Causes of haematoma formation after venipuncture include:

  • Small fragile veins
  • Needle too large
  • Excessive probing to find vein
  • Removing the needle prior to releasing the tourniquet
  • Needle going all the way through the vein
  • Needle only partially entering the vein allowing leakage
  • Applying pressure to gauze before the needle is removed

• To avoid haematoma formation from venipuncture:

  • Puncture only the uppermost wall of the vein just under the skin
  • Remove the tourniquets before removing the needle
  • Use the major superficial veins.
  • The needle used must fully penetrate the uppermost wall of the veins because partial puncture may allow blood to leak into the tissue just under the skin
  • Apply pressure to the puncture site

Infection

• The infection may be localized (thrombus, phlebitis) or systemic leading to septicemia.
• Peripheral intravenous cannula infections are more commonly associated with localized than systemic infection
• Infection can be caused by inadequate cleansing or poor technique.
• It is prevented by application of good aseptic technique

Nerve Damage

• Nerve injury is relatively rare, but is potentially serious and often results in malpractice lawsuits.
• If a nerve is hit, the patient may feel severe, sharp, electric, tingling pain.
• When nerve damage occurs, the venepuncture should be discontinued immediately, and the patient may need physical therapy.
• Nerve damage is caused by inappropriate sites or excessive probing.

Haemoconcentration

• Haemoconcentration may be caused by prolonged tourniquet application, massaging, squeezing or probing a site, long-term intravenous fluid therapy, scleroses or occluded veins, dehydration, and certain diseases.
• Haemoconcentration may cause a false increase in potassium ion, phosphorus, ammonia, and total protein.

Syncope and Fainting

• Syncope and fainting are caused by rapid fall in the blood pressure and is an autonomic nervous system reaction usually based on fear.
• Fear and phobia may occur in some patients on seeing the needle.

Petechiae & Excessive Bleeding

• Petechiae may be due to coagulation problems or abnormalities.
• In patients may bleed excessively after blood collection.
• The phlebotomist must ensure bleeding stops prior to the patient leaving.
• Excessive bleeding after venipuncture can occur in-patients on anticoagulants or drugs such as aspirin medication or drugs that decrease the number of platelets
• The patient should not be left alone until bleeding has stopped.

Other Phlebotomy Complications

• The patient may be allergic to the cleaning agent or other solutions used to disinfect the site so ask for any allergy pre test.
• Some patients have latex allergy.
• Iatrogenic anemia a hospital-acquired anemia can occur when large volumes of blood are taken for diagnostic purposes.
• In the event of an arterial puncture, the needle should be removed immediately and pressure applied over the site.
• Thrombosis: Thrombus is a solid mass derived from blood clot constituents in the vessels that is a clot